Can Folic Acid Help Migraine?

According to a study published in Headache, February 2015, it can. Previous studies have shown that supplementation with folic acid, B6 (pyridoxine), and B12 can reduce migraine disability, frequency, and severity. This study confirmed that finding but focused on the amount of folate. Patients were counseled about a diet that would provide 200 mcg. A multiple vitamin typical contains 100 mcg and prenatal vitamins 400. Doses higher than 400 require a prescription. One thousand micrograms equals 1 mg, and this is widely prescribed, safe, and cheap.

Jack Florin, MD
Neurologist

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Can Enhancing a Gene Prevent Alzheimer’s?

One in 5 people are born with the KL-VS variant of the klotho gene. They live 7% to 10% longer. They still undergo age-related declines in memory and learning, but they start at a higher baseline.

A study published in the February 11, 2015, issue of the Journal of Neuroscience reported that enhancing the activity of this gene in a mouse model provided resilience to their brains, and they functioned better even though they had amyloid buildup.

Researchers are excited over the possibility that a compound could increase the production of klotho and slow or perhaps prevent cognitive decline. This is a new area for research. Aging is the most important risk factor for Alzheimer’s, but exactly why this is the case is not known. Perhaps increasing activity of the klotho gene could counteract both aging and Alzheimer’s.

For more information, see Neurology Today, March 5, 2015.

Jack Florin, MD
Neurologist

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Can Exercise Help Patients with Parkinson’s?

A new study supports a large body of earlier research. This focused on exercise and falls in Parkinson’s. Sixty percent of Parkinson’s patients fall each year, and two-thirds of these fall repeatedly. Falls lead to injuries, pain, and fear of falling limits activities and reduces quality of life. Exercise programs have been shown to be effective in preventing falls in the general older population.

In the new Parkinson’s study, the program was 3 times a week for 6 weeks, with 40 to 60 minutes of balance and leg strengthening exercises, mostly unsupervised and mostly done at home. The number of falls was reduced among patients with less severe Parkinson’s but not with more severe. The reduction was almost 70% early in the course. Benefits of exercise wear off after 6 to 8 weeks, so it must be done regularly. One study in fact showed that exercising is as effective as adding another Parkinson’s medication.

Jack Florin, MD
Neurologist

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The Louis Vuitton Placebo Effect

Parkinson’s patients responded better when given an “expensive” placebo compared to a “cheap” one. The improvement in motor function approached that seen with use of levodopa. This was a study of 12 patients. The medication was an injection. They were told that both injections were active, not placebo, and that one cost $100 and the other $1500. The participants obviously were deceived – something hardly done in research – but the study was approved after extensive ethics reviews.

The study was published in Neurology, January 28th. An editorial in that edition pointed out that this price-driven placebo effect is similar to what happens with shoppers who are drawn to high-priced designer items.

This information comes on the heels of recent surprising placebo studies for migraine. Patients were given rizatriptan or placebo but were told that the rizatriptan was placebo and the placebo was the active drug. The patients who received the active drug but thought it was placebo did not respond whereas the patients who received placebo but thought it was the active drug did. A subset of patients received placebo and were told it was placebo and yet responded. They explained that they did not believe the Dr. would actually give them an ineffective treatment.

Jack Florin, MD
Neurologist

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The FDA Overreaches Again

First it was a warning about the risk of “serotonin syndrome” in migraine patients who were using antidepressants (SSRIs or SNRIs) along with triptans (Imitrex and others). When a physician prescribes both these medications for the same patient, pharmacists generate a response with a warning asking that the physician “override” it. The warning has not been withdrawn despite several studies showing evidence to the contrary, including one which identified over 600,000 patients in the US using this combination over the course of 1 year.

Next, the use of Azilect, a medication widely used for Parkinson’s, in combination with an SSRI or an SNRI was also considered a “warning.” This stands despite evidence showing that this is not significant.

Now, there is a new study in the Journal of General Internal Medicine published in January that was done in response to another FDA warning of 2 years ago, specifically that statins, widely used for hyperlipidemia, increase the risk for cognitive problems. Twenty-three studies with actual cognitive test data on over 29,000 patients were reviewed, and the meta-analysis showed no adverse effects.

Jack Florin, MD
Neurologist

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Can MS Patients Achieve Disease-Free Status?

This concept evolved from rheumatology. No evidence of disease activity is defined as no new MRI lesions, no relapses, no disability worsening. In many studies, the percentage of patients achieving this in the first 2 years varies from 28% to 42%.

In a new study, published in JAMA Neurology, February 2015, 46% of patients achieved no disease activity status after 1 year, but only 8% maintained this at 7 years. Even drugs thought to be very effective, such as Tysabri or Lemtrada, showed no disease activity in only 37% of patients. Gilenya’s numbers were 33%. Copaxone and interferons were about 20%.

The stem cell transplant study termed HALT-MS led to 75% no evidence of disease activity after 3 years; however, it is not a cure, and 25% of patients showed evidence of recurrence.

We are far from achieving this benchmark, but it should be the goal for MS patients.

Jack Florin, MD
Neurologist

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